The Kingdom of Tonga Health System Review

Health Systems in Transition Vol. 5 No. 6 2015

The Kingdom of Tonga Health System Review

Health Systems in Transition

Vol. 5 No. 6 2015

The Kingdom of Tonga Health System Review

Written by: Anna Rodney, University of Queensland, Brisbane, Australia Sione Hufanga, Chief Information Officer, Ministry of Health Tonga Sela Sausini Paasi, Chief Nursing Officer, Ministry of Health Tonga Paula Vivili, Secretariat of the Pacific Community Tu’akoi ‘Ahio, Principal Health Administrator, Ministry of Health Tonga Mafi Hufanga, Financial Analyst, Ministry of Health Tonga Edited by: Maxine Whittaker, University of Queensland, Brisbane, Australia Anna Rodney, University of Queensland, Brisbane, Australia Asia Pacific Observatory on Health Systems and Policies

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WHO Library Cataloguing in Publication Data The Kingdom of Tonga health system review (Health Systems in Transition, Vol. 5 No. 6 2015) 1. Health care reform. 2. Health expenditures. 3. Health system plans – organization and administration. 4. Tonga. I. Asia Pacific Observatory on Health Systems and Policies. II. World Health Organization Regional Office for the Western Pacific. ISBN 978 92 9061 719 8 (NLM Classification: WA 540 LT6) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: [email protected]). Requests for permission to reproduce or translate WHO publications–whether for sale or for non-commercial distribution–should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines (fax: +632 521 1036, email: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The named authors alone are responsible for the views expressed in this publication.

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Contents

Preface���������������������������������������������������������������������������������������������������������������� viii Acknowledgments................................................................................................ x List of abbreviations........................................................................................... xii Abstract................................................................................................................. xv Executive summary.......................................................................................... xvii 1 Introduction.................................................................................................. 1 Chapter summary.................................................................................................. 1 1.1 Geography and sociodemography............................................................. 2 1.2 Economic context......................................................................................... 6 1.3 Political context.......................................................................................... 10 1.4 Health status............................................................................................... 12 2 Organization and governance................................................................. 31 Chapter summary................................................................................................ 31 2.1 Overview of the health system................................................................. 32 2.2 Historical background............................................................................... 34 2.3 Organization................................................................................................ 35 2.4 Decentralization and centralization........................................................ 37 2.5 Planning....................................................................................................... 37 2.6 Intersectorality. .......................................................................................... 44 2.7 Health information management............................................................ 47 2.8 Regulation................................................................................................... 50 2.9 Patient empowerment............................................................................... 55 3 Financing..................................................................................................... 59 Chapter summary................................................................................................ 59 3.1 Health expenditure. ................................................................................... 59 3.2 Sources of revenue and financial flows.................................................. 66 3.3 Overview of the public financing system................................................ 68 3.4 Out-of-pocket payments........................................................................... 71 3.5 Voluntary health insurance. ..................................................................... 77 3.6 Other sources of financing (external support)...................................... 77 3.7 Payment mechanisms............................................................................... 79 iii

4 Physical and human resources. ............................................................. 81 Chapter summary................................................................................................ 81 4.1 Physical resources..................................................................................... 82 4.2 Human resources....................................................................................... 87 5 Provision of services............................................................................... 107 Chapter summary.............................................................................................. 107 5.1 Public health............................................................................................. 108 5.2 Patient pathways...................................................................................... 113 5.3 Primary/ambulatory care. ...................................................................... 117 5.4 Specialized ambulatory care/inpatient care........................................ 118 5.5 Emergency care........................................................................................ 122 5.6 Pharmaceutical care. .............................................................................. 123 5.7 Rehabilitation/intermediate care. ......................................................... 124 5.8 Long-term care. ....................................................................................... 125 5.9 Services for informal carers................................................................... 126 5.10 Palliative care. .......................................................................................... 126 5.11 Mental health care................................................................................... 126 5.12 Dental care................................................................................................ 128 5.13 Complementary and alternative medicine. ......................................... 128 5.14 Health services for specific populations.............................................. 129 6 Principal health reforms. ...................................................................... 130 Chapter summary.............................................................................................. 130 6.1 Analysis of reforms.................................................................................. 130 6.2 Future developments............................................................................... 135 7 Assessment of the health system........................................................ 141 Chapter summary.............................................................................................. 141 7.1 Stated objectives of the health system................................................. 142 7.2 Financial protection and equity in financing........................................ 143 7.3 User experience and equity of access to health care. ....................... 146 7.4 Health outcomes, health service outcomes and quality of care...... 150 7.5 Health system efficiency......................................................................... 157 7.6 Transparency and accountability........................................................... 160 8

Conclusions. ............................................................................................. 164

9 9.1 9.2 9.3 9.4

Appendices. .............................................................................................. 166 References. ............................................................................................... 166 Useful web sites....................................................................................... 177 HIT methodology and production process. .......................................... 177 About the authors. ................................................................................... 178

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List of Figures Figure 1.1 Population pyramid 2012...........................................................4 Figure 1.2 Top ten causes of certified inpatient and outpatient deaths by gender, 2011........................................................................ 17 Figure 1.3 Main causes of death in children under five years (2000–2010).............................................................................. 19 Figure 1.4 Leading causes of admission to hospital, 2011....................... 21 Figure 1.5 Nutritional status of children under five years of age, 2012... 24 Figure 2.1 Overview of the Ministry of Health.......................................... 33 Figure 2.2 Alignment of Ministry of Health planning with performance management systems and national plans.............................. 39 Figure 2.3 Results of the 2002 patient satisfaction survey...................... 56 Figure 3.1 Total health expenditure as a share (%) of GDP in selected countries, 2012........................................................................ 60 Figure 3.2 Health expenditure, per cent of GDP, Tonga and selected other countries, 1995–2009..................................................... 62 Figure 3.3 Health expenditure in US$PPP per capita in selected countries.................................................................................. 62 Figure 3.4 Government health expenditure as a per cent of total health expenditure, selected countries, latest available year........... 63 Figure 3.5 Financial flows......................................................................... 63 Figure 3.6 Regional comparison of OOPs as a percentage of total health expenditure, 2011......................................................... 72 Figure 3.7 Overview of user fee exemption processes............................. 75 Figure 4.1 Trends in physicians per 1000 population in Tonga and selected Pacific countries....................................................... 91 Figure 4.2 Trends in nurses and midwives per 1000 population, Tonga and selected Pacific countries................................................. 92 Figure 4.3 Trends in total number of physicians, nurses and midwives per 1000 population, Tonga and selected Pacific countries... 92 Figure 4.4 Trends in dental personnel per 1000 population, Tonga and selected Pacific countries....................................................... 93 Figure 4.5 Trends in pharmacy personnel per 1000 population, Tonga and selected Pacific countries................................................. 93 Figure 5.1 Overview of public health services in the Ministry of Health................................................................................ 109 Figure 5.2 Patient referral pathways from the periphery...................... 113 Figure 6.1 Conceptual overview of the structure of the THSPMP.......... 132 v

List of Tables Table 1.1 Trends in population/demographic indicators, selected years............................................................................5 Table 1.2 Macroeconomic indicators, selected years...............................9 Table 1.3 Mortality and health indicators, selected years...................... 13 Table 1.4 Crude incidence and death rates from NCDs in Tonga, 2008.......................................................................... 15 Table 1.5 Maternal, child and adolescent health indicators, selected years......................................................................................... 22 Table 1.6 Factors influencing health status for males and females, STEPS surveys 2004 and 2012................................................. 27 Table 2.1 Ministry of Health Outputs and Strategic Goals...................... 40 Table 2.2 Legislation relating to the Ministry of Health......................... 51 Table 2.3 Professional registration, legislation, occupational standards and competencies.................................................. 52 Table 3.1 Trends in health expenditure, selected years......................... 60 Table 3.2 Public health expenditure on health by service programme (2005/2006).............................................................................. 64 Table 3.3 Ministry of Health recurrent expenditure by service input over time......................................................................... 66 Table 3.4 Sources of revenue as a percentage of total expenditure on health.................................................................................. 67 Table 3.5 National OOP expenditure in 2005/2006................................. 72 Table 3.6 Revenue raised by user fees by region (TOP).......................... 76 Table 4.1 Distribution of health facilities by district............................... 82 Table 4.2 Distribution of hospital beds and occupancies by Island Divisions, 2006......................................................................... 84 Table 4.3 Admission statistics to Vaiola Hospital, 2011.......................... 84 Table 4.4 Comparative operating indicators in Pacific countries, latest available year................................................................. 85 Table 4.5 Staff employed by the Ministry of Health, density per 1000 population, 2005 and January 2013......................................... 89 Table 4.6 Health workers per 1000 population, Pacific countries, latest available year................................................................. 90

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Table 4.7 Average number of entrants and graduates by cadre, 2008–2012................................................................................ 98 Table 4.8 Highest clinical qualification of physicians in Tonga and other Pacific Island countries......................................... 103 Table 4.9 Doctors registered as specialists or undergoing specialty training in 2011...................................................................... 104 Table 4.10 Tongan nurses with postgraduate qualifications, 2010........ 105 Table 4.11 Qualifications of allied health workers in 2011..................... 106 Table 5.1 Overview of services provided by different levels of health facilities.................................................................................. 110 Table 5.2 Overseas referral institutions and the services provided..... 115 Table 5.3 Number of patients referred per specialty in 2009/2010...... 115 Table 5.4 Outpatient contacts per person in the Western Pacific Region, latest available year...................................... 117 Table 5.5 Visiting medical teams in 2010.............................................. 121 Table 7.1 Childhood immunization rates by socioeconomic characteristics, 2012............................................................. 153 Table 7.2 Childhood mortality rates by socioeconomic characteristics, 2012............................................................. 156

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Preface

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or development. HiTs examine approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health-care policies; and highlight challenges and areas that require more in-depth analysis. HiT profiles seek to provide information to support policy-makers and analysts in the development of health systems. They are building blocks that can be used: • to learn in detail about different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; • to describe the institutional framework, the process, content and implementation of health care reform programmes; • to highlight challenges and areas that require more in-depth analysis; • to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in different countries; and • to assist other researchers with more in-depth comparative health policy analysis. Compiling the profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services is based on a number of different sources, including the World Health Organization (WHO), national statistical offices, the Organization for Economic Co-operation and Development (OECD) health data, the International Monetary Fund (IMF), the World Bank, and any other sources considered useful by the authors. Data collection methods and definitions sometimes vary, but typically are consistent within each separate series.

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The HiT profiles can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. These profiles can also be used to inform comparative analyses of health systems. This series is an ongoing initiative and material is updated at regular intervals. In-between the complete renewals of a HiT, the APO has put in place a mechanism to update sections of the published HiTs, which are called the “Living HiTs” series. This approach of regularly updating a country’s HiT ensures its continued relevance to the member countries of the region. Comments and suggestions for the further development and improvement of the HiT series are most welcome and can be sent to [email protected]. HiT profiles and HiT summaries for Asia Pacific countries are available on the Observatory’s website at http:// www.wpro.who.int/asia_pacific_observatory/en/.

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Acknowledgments

The Health Systems in Transition (HiT) profile on the Kingdom of Tonga was written by Sione Hufanga (Ministry of Health, Kingdom of Tonga), Anna Rodney (University of Queensland), Sela Sausini Paasi (Ministry of Health, Kingdom of Tonga), Paula Vivili (Secretariat of the Pacific Community), Tu’akoi ‘Ahio (Ministry of Health, Kingdom of Tonga) and Mafi Hufanga (Ministry of Health, Kingdom of Tonga). It was edited by Anna Rodney and Maxine Whittaker, who also acted as Research Director. The Asia Pacific Observatory on Health Systems and Policies is grateful to Karen Carter at the Secretariat of the Pacific Community, Alejandro N. Herrin, Sunhwa Lee and Ninebeth Carandang from the Asian Development Bank, for reviewing the report. The authors are grateful to everyone at the Ministry of Health for their assistance in providing information and comments on previous drafts of the manuscript. Additionally, both administrative and clinical staff participated in a workshop looking at past and future reforms in the health system. They provided advice and recommendations about plans and policy options for the health system. Representatives from the Ministry of Finance and National Planning were also in attendance and are thanked for their valuable contribution. The current series of HiT profiles has been prepared by the staff of the Asia Pacific Observatory on Health Systems and Policies. The Observatory is a partnership between country governments, donors and development partners. The Observatory team working on the HiT profiles is led by Dale Huntington. Special thanks are extended to WHO and the WHO Regional Office for Western Pacific, from which some data on health and health services were extracted as well as to the Secretariat of the Pacific Community, the OECD and the World Bank. Thanks are also due to the Tonga Department of Statistics. The HiT profile reflects data available in February 2014. Research assistants:

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Nicola Hodge, University of Queensland, Brisbane, Australia Renata E. Mares, University of Queensland, Brisbane, Australia Reviewers: Karen Carter, Secretariat of the Pacific Community Sunhwa Lee, Asian Development Bank Ninebeth Carandang, Asian Development Bank Alejandro N. Herrin, Independent consultant

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List of abbreviations

ADB Asian Development Bank AIDS Acquired immune deficiency syndrome AUD Australian dollar AusAID Australian Agency for International Development (now DFAT) BMI body mass index BSc Bachelor of Science CEO Chief Executive Officer CMO Chief Medical Officer CPMS Central Pharmacy and Medical Stores CVD cardiovascular disease DALY disability-adjusted life years DFAT Australian Government Department of Foreign Affairs and Trade DHS Demographic and Health Survey DOTS directly observed treatment short course ER emergency room EU European Union FNU Fiji National University GBD Global Burden of Disease GDP gross domestic product GFC global financial crisis GNI gross national income HIES Household Income and Expenditure Survey HIS health information system HIV human immunodeficiency virus HR human resources HSSP Health Sector Support Project IMR infant mortality rate IT information technology

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ITU International Telecommunication Union JICA Japanese International Cooperation Agency KAP knowledge, attitudes and practices KPI key performance indicator KRA key result area LMIC low- and middle-income countries MAF MDG Acceleration Framework MBBS Bachelor of Medicine/Bachelor of Surgery MCH maternal and child health MDG Millennium Development Goals MMR maternal mortality ratio MoFNP Ministry of Finance and National Planning MTBF Medium Term Budget Framework NCD noncommunicable disease NCU national currency unit NGO nongovernmental organization NHA national health account NZ New Zealand NZD New Zealand dollar NZAID New Zealand Agency for International Development NZMTS New Zealand Medical Transfer Scheme ODA overseas development aid O&G Obstetrics and Gynaecology OOP out-of-pocket payment OPD Outpatient Department PACTAM Pacific Technical Assistance Mechanism PFM public and financial management PHIN Pacific Health Information Network PICT Pacific Island Countries and Territories POLHN Pacific Open Learning Health Net PPHSN Pacific Public Health Surveillance Network PPP purchasing power parity PSC Public Service Commission PvtHE private health expenditure QSSN Queen Salote School of Nursing RHD rheumatic heart disease

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SDP Strategic Development Plan SPC Secretariat of the Pacific Community SSCSiP Specialized Clinical Services in the Pacific STEPS STEPwise approach to risk factor surveillance STI sexually transmitted infection SWAp sector-wide approach TB tuberculosis THE total health expenditure THIS Tonga Hospital Information System THPMP Tonga Health Performance Management Programme THSPMP Tonga Health Sector Planning and Management Project THSSP Tonga Health Sector Support Program TOP Tongan pa’anga TSDF Tonga Strategic Development Framework USD United States dollar UN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USP University of the South Pacific VHI voluntary health insurance WB World Bank WHO World Health Organization WHR waist to hip ratio WISN workload indicator of staffing needs

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Abstract

Tonga is a small Pacific state comprised of over 170 islands and islets scattered in a north-south direction over 800 km, of which around 36 are inhabited. In 2011 the national census enumerated the population as 103 252. In 2013, Tonga was classified as an upper-middle income country with a gross national income (GNI) per capita of US$ 4240, and health expenditure per capita has increased significantly from US$ 163 in 2000 to US$ 245 in 2011. The Vision of the Ministry of Health is “to be the highest health-care provider in the Pacific as judged by international standards in 2020” and its mission is “to improve the health of the nation by providing quality care through promotion of good health, reducing morbidity, disability and premature (death) mortality”. Health services are provided by a network of 34 maternal and child health clinics, 14 health centres, three district hospitals and the tertiary referral hospital, Vaiola Hospital, located in the capital city, Nuku’alofa. Tonga has workforce densities which are higher than other low- and middle-income countries (LMICs) in the Pacific but significantly below high-income neighbours, and suffers from “brain drain”. The government is the main financer of the health system, providing close to half (47%) of financing in 2007/2008, supplemented by a large degree of donor and development partner funding (38%) and an average of 10% of total health expenditure coming from household outof-pocket payments (OOPs). Since the 1990s, Tonga has undergone many rounds of development partner-supported health reform and has an established National Health Accounts and health information system that are used to support planning, resource allocation and evaluation. Tonga has had one of the best overall levels of health within the Pacific as a result of a dramatic reduction in communicable diseases and maternal and child mortality since the 1950s. However, the emergence of lifestyle diseases, particularly diabetes and cardiovascular disease, poses a huge challenge to the health system and the overall health of the nation. The 2004 STEPS survey revealed that an alarming 99.9% of the adult population

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are estimated to be at moderate to high risk of developing a noncommunicable disease (NCD). Tonga prioritized NCDs within the MDG acceleration framework; produced the Tonga Commitment to Promote Healthy Lifestyles and Supportive Environment in 2003 at the Pacific Ministers of Health Meeting; and was the first Pacific Island country to develop a comprehensive NCD strategy based on the WHO Stepwise Framework for Action. The original plan, the National Strategy to Prevent and Control NCDs 2004–2009, has now been replaced by a second plan covering 2010–2015. Moving forward, Tonga faces the challenge of ensuring that quality primary health-care services can be maintained in remote areas. Also, in meeting the needs of the disease burden now dominated by NCDs and chronic conditions, the key priority for the health system is to reorientate its focus on prevention and treatment of NCDs, and to continue to strengthen the health system within financial and human resource constraints. This requires increased efficiency and investigating alternate sources of financing. The National Health Strategic Plan (NHSP 2011–2015) prioritizes prevention and system effectiveness under the banner of “doing better” and the aim of current reforms is to strengthen the system to become “strong and affordable” building on the resilience of rural health services of the last two decades.

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Executive summary

Tonga has had one of the best overall levels of health within the Pacific as a result of a dramatic reduction in communicable diseases and maternal and child mortality since the 1950s. Tonga is on target to achieve the Millennium Development Goals (MDG) around maternal and child mortality reflecting an effective primary health-care system, good public health infrastructure and comprehensive antenatal and postnatal care, immunization, water, sanitation and waste disposal programmes. The Ministry of Health reports that 100% of the population can access appropriate health-care services with a regular supply of essential drugs within a one-hour walk. In spite of these successes, however, the emergence of lifestyle diseases, particularly diabetes and cardiovascular disease, poses a huge challenge to the health system and the overall health of the nation. The 2004 STEPS survey revealed that an alarming 99.9% of the adult population are estimated to be at moderate to high risk of developing a noncommunicable disease (NCD). As of 2011, WHO estimates that NCDs account for 74% of all deaths in Tonga and are a leading cause of premature death and disability. Furthermore, research conducted in 2010 concluded that previous methods of estimating life expectancy for Tonga did not adequately cope with the high level of adult mortality and based on improved data, the estimated life expectancy was revised downward by five years for both males and females, to 65 years and 69 years, respectively (Hufanga et al., 2012). As 39% of Tongans are under the age of 15, primary prevention of obesity, inactivity and poor nutritional habits will be a key strategy for future population health. In response, in 2004 the Tongan Government, with high-level support from multiple ministries, was the first country in the Pacific to launch a National Strategy to Prevent and Control NCDs. However, despite many preventative strategies implemented over the past decade, NCD risk factors continue to rise. The real challenge now is for Tonga to adapt its strong primary health-care system to deal with the range of emerging issues, particularly the large financial burden associated with chronic and noncommunicable diseases. The Ministry of Health is mandated to provide the administration and delivery of preventive and curative public health services in Tonga under xvii

the Health Services Act. Health-care services are decentralized and managed geographically through four health districts which correspond to the main island groups. Six functional divisions are also responsible for service delivery and planning. Donor and development partners are also important in the governance and organization of the health system, providing capital investment funding, technical assistance and programmatic support. In conjunction with the Government of Tonga, they also fund teams of visiting overseas medical specialists and transfers of patients to overseas hospitals for advanced and complex care that is not available in Tonga. Apart from a relatively large cohort of unregulated and widely-utilized traditional healers, the private health sector is small, consisting of a limited number of private pharmacies and a few government health workers engaged in dual practice. As such there is no formalized regulation of these providers, nor is there regulation of private health services or insurers. Clinical staff are regulated by several key legislations and are registered and licenced by professional boards. With donor support, particularly the Tonga Health Sector Planning and Management Project (THSPMP), the planning, budgeting and management capacity of the Ministry of Health has grown considerably. Health sector planning is aligned with the Government’s Strategic Development Plan and Framework, and underpinned by the Ministry’s Vision and Mission statements which are described in the Corporate Plan, created every three years. The Corporate Plan sets out six key result areas, targets and key performance indicators against which they are measured. The Ministry has also institutionalised several relatively sophisticated performance management systems which complement quarterly and annual reporting, namely the Balanced Scorecard and the Executive Performance Appraisal System. One patient satisfaction survey has been undertaken at Vaiola Hospital in 2002 and the level of satisfaction is generally high. Complaints about cleanliness and comfort are likely to have been addressed since the upgrade and refurbishment of the hospital between 2002 and 2014. The Ministry of Health continues to prioritize the improvement of customer service and has made it a key result area in the latest Corporate Plan. Since 2000, government expenditure on health as a proportion of total health expenditure has averaged above 80%, at an average 4% of GDP and with the health sector consistently receiving a relatively large portion (12%) of total government funding. In the last NHA (2007/2008) total

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health expenditure was roughly TOP 40 million and health expenditure per capita has increased significantly from US$ 163 in 2000 to US$ 245 in 2011. The Government is the main financer of the health system, providing close to half (47%) of financing in 2007/2008, supplemented by a large degree of donor and development partner funding (38%) with only an average of 10% of total health expenditure coming from household out-of-pocket payments (OOPs), a relatively small figure compared to regional averages for the Asia Pacific region. Payments to traditional healers account for the majority of OOPs. User fees were introduced for some services in 2009 and raise approximately TOP 1 million per year. Although fee exemptions and a safety net are in place to protect the poor, there is a lack of research to show whether this has been effective in protecting the poor without decreasing service utilization. Voluntary health insurance currently only accounts for around 3% of total health expenditure and recent attempts to implement social health insurance for the 12% of the population employed in the formal sector failed to pass through Cabinet. With the double burden of disease and Tonga’s commitment to provide universal health care, the Government must look at alternate financing mechanisms and increasing health system efficiency in particular through budgeting more for preventative health. Health services are provided by a network of 34 maternal and child health clinics, 14 health centres, three district hospitals and the tertiary referral hospital, Vaiola Hospital, located in the capital city, Nuku’alofa. The four hospitals also provide primary health care to the populations of their respective island groups through outpatient and emergency departments; in fact, over 90% of health services are delivered from the hospitals. There have been several donor-funded infrastructure programmes over the past few years, the most notable of which was the multimillion dollar redevelopment and upgrade of Vaiola Hospital. The hospital has been designed and planned to meet the needs of the population now and into the future. Maintenance and upkeep of health facilities do, however, remain an ongoing challenge within constrained operational budgets. Purchasing new equipment and ensuring that the outer island facilities have adequate levels of basic, functional equipment is also challenging and often requires donor supplementation. Tonga has workforce densities which are higher than other low and middle-income countries (LMIC) in the Pacific but significantly below high-income neighbours. Tonga does suffer from brain drain, and routinely experiences critical deficiencies, particularly for in-demand

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medical specialists such as surgeons and anaesthetists. Key deficiencies have been filled with funding from the Australian Aid-funded Tonga Health Systems Support Program (THSSP). However, this is a costly option and a more sustainable method must be established. Local training of health workers is limited, with the Queen Salote School of Nursing providing the only accredited in-country health professional training, in basic and post-basic nursing. The Ministry of Health also provides training courses for some cadres of health professionals such as health officers and dental assistants, but the programmes are ad hoc and unaccredited. There is no medical education available in Tonga and most doctors enrol at Fiji National University or at other universities in Australia, New Zealand, or more recently, in Cuba. With close to a quarter of the workforce reaching retirement age in the next ten years, workforce succession planning is vital and innovative use of technologies such as video-conferencing (e-health) will be needed to overcome workforce shortages. The Government currently provides the majority of the country’s primary health care through the network of reproductive and child health clinics, health centres and hospitals. However, patients, particularly in rural and remote areas, often bypass the lower-level health services and go directly to a hospital, which can result in late presentation and reduced technical efficiency of the health system. Ensuring that quality primary health-care services can be maintained in remote areas is a major challenge for Tonga. The range and scope of secondary and tertiary services also need to be expanded, in particular to treat and limit complications due to NCDs. For example, Tonga is not currently able to deliver complex surgical procedures such as specialized cardiac, paediatric and neurological surgery nor multimodal cancer therapies in a cost-effective and sustainable manner. Tonga relies on overseas transfers and the visits of specialist medical teams to provide these services, and this is likely to be the case for the foreseeable future. The health system is also very limited in the scope of available rehabilitation services and lacks adequate human resources, medical equipment and assistive devices to cater for the growing demand related to the rise in lifestyle diseases and chronic conditions. In general, the majority of rehabilitation, long-term care and care for those with disabilities is provided by family members although a small number of NGOs and faith-based organizations also provide limited services, predominantly on Tongatapu. Whilst Vaiola Hospital has a psychiatric unit, mental health care is also limited in scope on outer islands where it is

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generally delivered by health staff with no formal mental health training. Tonga has a significant cohort of traditional healers who, although not recognized as a part of the formal health system, play an important role in providing health services, particularly in remote areas. Additionally, a small number of private practitioners also provide fee-based health services, mainly around Nuku’alofa. As the Ministry of Health endeavours to expand and improve the quality of primary and secondary health services, it is imperative that they engage and work with all health providers including those who operate outside of the formal public system. Since the 1990s, Tonga has undergone many rounds of development partner-supported health reform. Programmes such as the World Bank’s Health Sector Support Project, the Australian Aid-funded Tonga Health Sector Planning and Management Project and the more recent Health Systems Support Program, have helped to strengthen the Ministry of Health’s capacity, particularly in planning, budgeting and financial management. These programmes have also been responsible for significant upgrading and development of key infrastructure. Donor funding has also led to major improvements and upgrades to the health information system and the use of data for decision-making, particularly the system of National Health Accounts (NHAs). As a result the Ministry of Health now has the basic governance and management infrastructure, together with the skills required, to lead further reform processes on its own. While the Government has been praised internationally for prioritizing NCDs within the MDG acceleration framework; a key priority now is for the health sector to reorientate itself to focus on prevention and treatment of NCDs. It must overcome identified weaknesses in the fight against NCDs, including insufficient organizational management and funding for NCDs, and the need for better NCD monitoring, evaluation and sur­veillance. The health sector must also increase efficiency and look for alternate means of financing so that it can continue to strengthen institutional capacity and provide the required physical and human resources to effectively minimize the NCD epidemic and complete the unfinished MDG agenda. The health system currently provides a high degree of financial protection with out-of-pocket payments accounting for only 10% of total health expenditure and only 0.5% of average total annual household expenditure, a level which is significantly below the average 2–5% of other countries in the East Asia and Pacific region. There is, however,

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some inequity in terms of access and financing which is due, in large part, to the difficulties of maintaining adequate health services in areas with low population density. For example, it was shown that households living in rural areas spend slightly less than half the amount that urban households spend directly on health and medical services each year (although this figure does not take into account the indirect expenses for health-seeking travel such as time off work and transport costs which should also be considered). Despite the Ministry of Health ascertaining that 100% of the population can access appropriate health-care services with a regular supply of essential drugs within a one-hour walk, quality and scope of services is an issue in rural areas. Furthermore, a key area that requires strengthening is the disaggregation of data by gender, age, race, and socioeconomic group as it is not currently possible to ascertain whether there is inequity in health outcomes amongst different population groups in Tonga. In terms of providing universal health coverage, Tonga must ensure that the enforcement of user fees which were mandated in 2009 does not further jeopardise equity and that, alternately, non-enforcement of user fees does not reduce the efficiency of the system in terms of appropriate referrals. The scope, coverage and quality of services also need to be further defined and monitored in order to maximize both allocative and technical efficiencies of the health system – one of the few areas in which the health system may be able to increase fiscal space in the future. In terms of quality and health-care effectiveness, despite the significant improvements that the Ministry of Health has made in terms of accountability and transparency under the World Bankfunded Health Sector Support Project (HSSP) and other programmes, the creation and implementation of an integrated quality in health-care programme is recommended. Additionally, more budget should be funnelled towards preventative health services in the recognition that delivery of cost-effective primary and secondary prevention strategies for NCDs will improve efficiency in health care over the long term and lower expenditures associated with secondary and tertiary care.

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1 Introduction

Chapter summary Prior to the rise in noncommunicable diseases (NCDs), Tonga had one of the best overall levels of health in the Pacific, having achieved a dramatic reduction in communicable diseases and maternal and child mortality since the 1950s. Tonga is on target to achieve the MDG goals around maternal and child mortality, reflecting an effective primary health-care system, good public health infrastructure and comprehensive antenatal and postnatal care, immunization, water, sanitation and waste disposal programmes. The Ministry of Health reports that 100% of the population can access appropriate health-care services, with a regular supply of essential drugs within a one-hour walk. In spite of these successes, the emergence of lifestyle diseases, particularly diabetes and cardiovascular disease, poses a huge challenge to the health system and the overall health of the nation. The 2004 STEPS survey estimated that an alarming 99.9% of the adult population are at moderate to high risk of developing a NCD. NCDs are now the leading cause of premature death and disability in Tonga (WHO, 2011). Due in large part to premature deaths from NCDs, and based on research showing that previous methods were likely to have overestimated life expectancy, the estimated life expectancy for both males and females was lowered by five years in 2011, to 65 years and 69 years, respectively (Hufanga et al., 2012). As 39% of Tongans are aged under 15, primary prevention of obesity, inactivity, and poor nutritional habits will be a key prevention strategy for a healthy future population of adults. The Tongan Government has been at the forefront of mounting a comprehensive strategy to fight these conditions, with the highest levels of Government working together to launch the National Strategy to Prevent and Control NCDs in 2004, the first such commitment in the Pacific. The challenge now for Tonga is to adapt its primary health-care system, which has successfully delivered maternal and child health interventions, to deal with the range of emerging issues, and in particular

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the large financial burden associated with chronic and noncommunicable disease.

1.1 Geography and sociodemography The key source of information for this section is the most recent Census, conducted in 2011 (Statistics Department Tonga, 2013); unless otherwise stated, data is taken from this report. Geography: The Kingdom of Tonga is located in the southern Pacific Ocean, approximately 900 km south of Samoa and approximately 700 km east-southeast of Fiji. Tonga is comprised of over 170 islands and islets scattered in a north-south direction over 800 km, of which around 36 are inhabited. There are five administrative divisions based on the major island groups, namely: • Tongatapu, the main island where the capital, Nuku’alofa is situated • Vava’u • Ha’apai • ‘Eua • the Ongo Niua group, referred to as the Niuas. Population growth: Tonga had a population of 103 252 in the 2011 Census, having increased 1.2% since the 2006 Census at an annual growth rate of 0.2% (Statistics Department Tonga, 2013). In 2011 there were 18 033 households, a 3.4% rise on the 2006 figure. The population growth rate is relatively low, considering a crude birth rate of about 27 per 1000 population and the fact that child mortality rates are amongst the lowest in the Pacific (Tonga Department of Statistics and Tonga Ministry of Health et al., 2014). The explanation is found in the high net emigration rate, which averaged 19.8% between 1986 and 1996 and has continued, with around 1.8% of the population emigrating every year between 1996 and 2006. Those aged between 15 and 24 years of age are the largest cohort to emigrate (Statistics Department Tonga, 2008). It is now estimated that as many Tongans live overseas as in Tonga, with large communities in New Zealand, the United States and Australia. Strong relationships between Tongan communities residing in Tonga and abroad contribute significantly to the Tongan economy through remittances and imports (UNDP, 2013). Seventy-three per cent of Tonga’s population live on the main island, Tongatapu, and roughly a third (35%) of the population live in greater

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Nuku’alofa, Tonga’s capital city. The population on Tongatapu has increased by 5.1% since 2006 as people increasingly move there for work and educational opportunities. Careful monitoring of internal and external migration is thus important in order to provide adequate health services to the population and understand health determinants in urban and rural settings. The remainder of the population is dispersed across the outer island groups, with Vava’u accommodating 15% of the population, Ha’apai 6%, Eua 5% and 1% in the Niuas (Statistics Department Tonga, 2013). Population structure: Demographic transition has been relatively slow in Tonga, with the median age of the population in 2011 being 21 years of age and only 8% of the population currently aged 60 and over (Statistics Department Tonga, 2013). Out-migration coupled with high birth rates and relatively low infant mortality mean that almost one in four Tongans (39%) are aged less than 15, as shown in Figure 1.2. Just under half (49.7%) of the population is female; however, as females have a life expectancy which is five years greater than males, the proportion of the population which is female will increase in the future. The dependency ratio of 84 is high, meaning that 100 people of working age (15–59) are needed to support 84 dependents who do not or are not able to work, a figure which is elevated by the high out-migration of the working-age population. Ethnicity: Tonga’s population is very homogenous, with over 97% being Polynesian or part-Polynesian. The 2.5% of foreign nationality are mainly Chinese (843 individuals), European (569 individuals), Fijian (304 individuals), other Pacific Islander (236 individuals), other Asian (186 individuals), and Fijian Indian (133 individuals) (Statistics Department Tonga, 2013). As shown in Table 1.1, the average household size is relatively large at 5.7 members. The fertility rate of 4.1 births per woman has declined significantly from around 7.4 in 1960. The birth rate of roughly 27 per 1000 has remained constant at a relatively high level since 2006. The crude death rate has increased from 5.0 per 1000 in 2006 to 6.4 in 2011, but this figure is still relatively low. Roughly a quarter (23.5%) of the population live in urban areas,1 comprised of the villages of Kolofo’ou, Ma’ufanga and Kolomotu’a, which make up Nuku’alofa in Tongatapu. The population density in the aforementioned urban areas (2123 people/km2) is around 17 1

The definition of rural/urban is however not particularly meaningful in a small country such as Tonga, with the main criterion used by the National Department of Statistics being that urban areas have a population of 5000 or more inhabitants.

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times higher than that of rural areas (124 people/km2), with the average population density across Tonga being 159 people/km2. Again, the density varies greatly across the island groups, from only 18 people/km2 in the Niuas to 290 people/km2 on Tongatapu. As in other small island nations in the Pacific and elsewhere, general socioeconomic development and provision of health services to remote, low-density areas is a challenge for Tonga. Language: Tongan is the official language, but English is taught in all primary schools, is the language of instruction in most secondary schools, and is increasingly being used as the official language. Government documents are often published in both languages. Literacy is high (98.2%) in both males and females, with few people (11%) literate in Tongan only and around 86% literate in both Tongan and English or other languages. Figure 1.1 Population pyramid 2012 80+ 70–74

Age group

60–64 50–54 40–44 30–34 20–24 10–14